Der Anaesthesist

, Volume 56, Issue 1, pp 7–17

Schlafstörungen bei kritisch kranken Patienten

Leitthema

Zusammenfassung

Schlaf ist ein essenzieller Bestandteil des Lebens. Für eine intakte Immunabwehr, für kognitive und muskuläre Funktionen scheint Schlaf wichtig zu sein. Subjektive Schlafstörungen wurden in 20% der arbeitenden Population gefunden und nehmen mit dem Alter zu. Schlafstörungen konnten bei mehr als 50% der Patienten in kritischem Zustand nachgewiesen werden. Bei kritisch kranken Patienten ist der Schlaf bisher nur unzureichend wissenschaftlich untersucht worden. Zur Schlafmessung stehen Fragebogen und als einziges objektivierendes Verfahren die Polysomnographie zur Verfügung. Schlafstörungen in der Intensivstation haben meist multifaktorielle Ursachen: patientenbedingte Pathologien, wie Status nach größerer Chirurgie, Sepsis, akuter oder chronischer Lungenschaden, Herzinsuffizienz, Schlaganfall oder Epilepsie; therapeutische Interventionen, wie z. B. die mechanische Ventilation, Lärm verursachende technische Geräte, Schmerzen und Medikamente. Neben pharmakologischen Behandlungskonzepten mit Analgetika und zeitlich limitierten Sedativa sollten umwelthygienische Maßnahmen mit Musik zur Entspannung, nächtliche Lärmreduktion und Tageszeitpräsentation ergriffen werden. Bevor evidenzbasierte „guidelines“ erstellt werden können, muss eine intensivierte Forschung im Bereich Schlaf und kritische Krankheit durchgeführt werden. Mit großen Kohortenstudien sollte untersucht werden: 1. Welche Anteile der Schlafstörungen kritisch kranker Patienten Folge von Krankheiten oder Trauma und damit nichtbeeinflussbar sind, 2. ob der Schweregrad der Schlafstörungen Ausdruck von der Schwere der Krankheit oder des Traumas ist, 3. welcher Anteil Folge medizinischer Interventionen und damit beeinflussbar ist. Mithilfe der nach Pathologie stratifizierten und randomisierten Studien sollten nichtpharmakologische und pharmakologische Konzepte zur Schlafverbesserung getestet werden. Dabei sollten sowohl nosokomiale Infektionen als auch kognitive Funktionen und respiratorische Muskelkraft berücksichtigt werden. Dann kann beurteilt werden, ob es sinnvoll ist, Schlafstörungen engmaschig zu überwachen, um sie als Verlaufsmaß des Therapieerfolgs und der kurzfristigen Lebensqualität zu nutzen. Wichtig ist, dass solche Studien einen genügend langen Follow-up-Zeitraum haben, um allfällige Entzugserscheinungen pharmakologischer Interventionen zu erfassen.

Schlüsselwörter

Schlaf Intensivpatient Intensivtherapie Schlafmessung Polysomnographie 

Sleep disturbances in critically ill patients

Abstract

Sleep is an essential part of life with many important roles which include immunologic, cognitive and muscular functions. Of the working population 20% report sleep disturbances and in critically ill patients an incidence of more than 50% has been shown. However, sleep disturbances in the intensive care unit (ICU) population have not been investigated in detail. Sleep disturbances in ICU patients have a variety of reasons: e.g. patient-related pathologies like sepsis, acute or chronic pulmonary diseases, cardiac insufficiency, stroke or epilepsy, surgery, therapeutical interventions like mechanical ventilation, noise of monitors, pain or medication. Numerous scales and questionnaires are used to quantify sleep and the polysomnogramm is used to objectify sleep architecture. To improve sleep in ICU patients concepts are needed which include in addition to pharmacological treatment (pain reduction and sedation) synchronization of ICU activities with daylight, noise reduction and music for relaxation. In order to establish evidence-based guidelines, research activities about sleep and critical illness should be intensified. Questions to be answered are: 1) Which part of sleep disturbances in critically ill patients is directly related to the illness or trauma? 2) Is the grade of sleep disturbance correlated with the severity of the illness or trauma? 3) Which part is related to the medical treatment and can be modified or controlled? In order to define non-pharmacological and pharmacological concepts to improve sleep quality, studies need to be randomized and to include different ICU populations. The rate of nosocomial infections, cognitive function and respiratory muscle function should be considered in these studies as well. This will help to answer the question, whether it is useful to monitor sleep in ICU patients as a parameter to indicate therapeutical success and short-term quality of life. Follow-up needs to be long enough to detect adverse effects of withdrawal symptoms after termination of analgesia and sedation or delirium.

Keywords

Sleep Critically ill patient Intensive care Sleep measurement Polysomnography 

Literatur

  1. 1.
    Aaron JN, Carlisle CC, Carskadon MA et al. (1996) Environmental noise as a cause of sleep disruption in an intermediate respiratory care unit. Sleep 19: 707–710PubMedGoogle Scholar
  2. 2.
    Bergbom-Engberg I, Haljamae H (1989) Assessment of patients‘ experience of discomforts during respirator therapy. Crit Care Med 17: 1068–1072PubMedGoogle Scholar
  3. 3.
    Berger M, Calker D van, Riemann D (2003) Sleep and manipulations of the sleep-wake rhythm in depression. Acta Psychiatr Scand [Suppl] : 83–91Google Scholar
  4. 4.
    Bourne RS, Mills GH (2004) Sleep disruption in critically ill patients – pharmacological considerations. Anaesthesia 59: 374–384CrossRefPubMedGoogle Scholar
  5. 5.
    Chambrin MC, Ravaux P, Calvelo-Aros D et al. (1999) Multicentric study of monitoring alarms in the adult intensive care unit (ICU): a descriptive analysis. Intensive Care Med 25: 1360–1366CrossRefPubMedGoogle Scholar
  6. 6.
    Chee MW, Choo WC (2004) Functional imaging of working memory after 24 hr of total sleep deprivation. J Neurosci 24: 4560–4567Google Scholar
  7. 7.
    Chen HI (1991) Effects of 30-h sleep loss on cardiorespiratory functions at rest and in exercise. Med Sci Sports Exerc 23: 193–198PubMedGoogle Scholar
  8. 8.
    Chervin RD, Burns JW, Ruzicka DL (2005) Electroencephalographic changes during respiratory cycles predict sleepiness in sleep apnea. Am J Respir Crit Care Med 171: 652–658CrossRefPubMedGoogle Scholar
  9. 9.
    Chesson A Jr, Hartse K, Anderson WM et al. (2000) Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep 23: 237–241PubMedGoogle Scholar
  10. 10.
    Cooper AB, Thornley KS, Young GB et al. (2000) Sleep in critically ill patients requiring mechanical ventilation. Chest 117: 809–818CrossRefPubMedGoogle Scholar
  11. 11.
    Delafosse JY, Leger D, Quera-Salva MA et al. (2000) Comparative study of actigraphy and ambulatory polysomnography in the assessment of adaptation to night shift work in nurses. Rev Neurol 156: 641–645Google Scholar
  12. 12.
    Diby M, Walder B, Hadorn F et al. (2003) Is it worthwhile to implant a CQI programm for pain management after major surgery? Intensive Care Med 29 [Suppl 1]: S67Google Scholar
  13. 13.
    Dobbin CJ, Bartlett D, Melehan K et al. (2005) The effect of infective exacerbations on sleep and neurobehavioral function in cystic fibrosis. Am J Respir Crit Care Med 172: 99–104CrossRefPubMedGoogle Scholar
  14. 14.
    Dyken ME, Somers VK, Yamada T et al. (1996) Investigating the relationship between stroke and obstructive sleep apnea. Stroke 27: 401–407PubMedGoogle Scholar
  15. 15.
    Edell-Gustafsson UM, Hetta JE, Aren GB, Hamrin EK (1997) Measurement of sleep and quality of life before and after coronary artery bypass grafting: a pilot study. Int J Nurs Pract 3: 239–246PubMedGoogle Scholar
  16. 16.
    Edwards GB, Schuring LM (1993) Pilot study: validating staff nurses‘ observations of sleep and wake states among critically ill patients, using polysomnography. Am J Crit Care 2: 125–131PubMedGoogle Scholar
  17. 17.
    Ely EW, Shintani A, Truman B et al. (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291: 1753–1762CrossRefPubMedGoogle Scholar
  18. 18.
    Everson CA (2005) Clinical assessment of blood leukocytes, serum cytokines, and serum immunoglobulins as responses to sleep deprivation in laboratory rats. Am J Physiol Regul Integr Comp Physiol 289: R1054–1063PubMedGoogle Scholar
  19. 19.
    Frick S, Guegueniat S, Diby M et al. (2002) Sleep is disturbed after cardiac surgery for at least one month. Intensive Care Med 28: 109CrossRefGoogle Scholar
  20. 20.
    Frisk U, Nordstrom G (2003) Patients‘ sleep in an intensive care unit – patients‘ and nurses‘ perception. Intensive Crit Care Nurs 19: 342–349CrossRefPubMedGoogle Scholar
  21. 21.
    Frisk U, Olsson J, Nylen P, Hahn RG (2004) Low melatonin excretion during mechanical ventilation in the intensive care unit. Clin Sci 107: 47–53CrossRefPubMedGoogle Scholar
  22. 22.
    Gentili A, Godschalk MF, Gheorghiu D et al. (1996) Effect of clonidine and yohimbine on sleep in healthy men: a double-blind, randomized, controlled trial. Eur J Clin Pharmacol 50: 463–465CrossRefPubMedGoogle Scholar
  23. 23.
    Graves L, Pack A, Abel T (2001) Sleep and memory: a molecular perspective. Trends Neurosci 24: 237–243CrossRefPubMedGoogle Scholar
  24. 24.
    Heffner JE (2000) A wake-up call in the intensive care unit. N Engl J Med 342: 1520–1522CrossRefPubMedGoogle Scholar
  25. 25.
    Helton MC, Gordon SH, Nunnery SL (1980) The correlation between sleep deprivation and the intensive care unit syndrome. Heart Lung 9: 464–468PubMedGoogle Scholar
  26. 26.
    Higgins PA (1998) Patient perception of fatigue while undergoing long-term mechanical ventilation: incidence and associated factors. Heart Lung 27: 177–183CrossRefPubMedGoogle Scholar
  27. 27.
    Hurel D, Loirat P, Saulnier F et al. (1997) Quality of life 6 months after intensive care: results of a prospective multicenter study using a generic health status scale and a satisfaction scale. Intensive Care Med 23: 331–337CrossRefPubMedGoogle Scholar
  28. 28.
    Iliescu EA, Yeates KE, Holland DC (2004) Quality of sleep in patients with chronic kidney disease. Nephrol Dial Transplant 19: 95–99CrossRefPubMedGoogle Scholar
  29. 29.
    Incalzi RA, Bellia V, Maggi S et al. (2002) Reversible bronchial obstruction and disease-related health status in COPD. Qual Life Res 11: 517–525CrossRefPubMedGoogle Scholar
  30. 30.
    Jacovone J, Young J (1989) Use of pulmonary rehabilitation strategies to wean a difficult-to-wean patient: case study. Crit Care Nurse 18: 29–37Google Scholar
  31. 31.
    Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14: 540–545PubMedGoogle Scholar
  32. 32.
    Johns MW, Large AA, Masterton JP, Dudley HA (1974) Sleep and delirium after open heart surgery. Br J Surg 61: 377–381PubMedGoogle Scholar
  33. 33.
    Jones C, Griffith RD, Humphris G, Skirrow PM (2001) Memory, delusions and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Crit Care Med 29: 573–580CrossRefPubMedGoogle Scholar
  34. 34.
    Kahn DM, Cook TE, Carlisle CC et al. (1998) Identification and modification of environmental noise in an ICU setting. Chest 114: 535–540PubMedGoogle Scholar
  35. 35.
    Kavey NB, Ahshuler KZ (1979) Sleep in herniorrhaphy patients. Am J Surg 138: 683–687CrossRefPubMedGoogle Scholar
  36. 36.
    Kelley KW, Bluthe RM, Dantzer R et al. (2003) Cytokine-induced sickness behavior. Brain Behav Immun 17 [Suppl 1]: S112–118Google Scholar
  37. 37.
    Knill RL, Moote CA, Skinner MI, Rose EA (1990) Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week. Anesthesiology 73: 52–61PubMedGoogle Scholar
  38. 38.
    Krachman SL, D’Alonzo GE, Criner GJ (1995) Sleep in the intensive care unit. Chest 107: 1713–1720PubMedGoogle Scholar
  39. 39.
    Landrigan CP, Rothschild JM, Cronin JW et al. (2004) Effect of reducing interns‘ work hours on serious medical errors in intensive care units. N Engl J Med 351: 1838–1848CrossRefPubMedGoogle Scholar
  40. 40.
    Lange T, Perras B, Fehm HL, Born J (2003) Sleep enhances the human antibody response to hepatitis A vaccination. Psychosom Med 65: 831–835CrossRefPubMedGoogle Scholar
  41. 41.
    Larson SJ (2002) Behavioral and motivational effects of immune-system activation. J Gen Psychol 129: 401–414PubMedGoogle Scholar
  42. 42.
    Laube I, Seeger R, Russi EW, Bloch KE (1998) Accidents related to sleepiness: review of medical causes and prevention with special reference to Switzerland. Schweiz Med Wochenschr 128: 1487–1499PubMedGoogle Scholar
  43. 43.
    Lee HJ, Kim L, Suh KY (2003) Cognitive deterioration and changes of P300 during total sleep deprivation. Psychiatry Clin Neurosci 57: 490–496Google Scholar
  44. 44.
    Lockley SW, Cronin JW, Evans EE et al. (2004) Effect of reducing interns‘ weekly work hours on sleep and attentional failures. N Engl J Med 351: 1829–1837CrossRefPubMedGoogle Scholar
  45. 45.
    Malow BA, Levy K, Maturen K, Bowes R (2000) Obstructive sleep apnea is common in medically refractory epilepsy patients. Neurology 55: 1002–1007Google Scholar
  46. 46.
    Mayers AG, Baldwin DS (2005) Antidepressants and their effect on sleep. Hum Psychopharmacol 20: 533–559CrossRefPubMedGoogle Scholar
  47. 47.
    Mazza M, Della Marca G, Risio S de et al. (2004) Sleep disorders in the elderly. Clin Ter 155: 391–394PubMedGoogle Scholar
  48. 48.
    Meredith C, Edworthy J (1995) Are there too many alarms in the intensive care unit? An overview of the problems. J Adv Nurs 21: 15–20CrossRefPubMedGoogle Scholar
  49. 49.
    Miyazaki S, Uchida S, Mukai J, Nishihara K (2004) Clonidine effects on all-night human sleep: opposite action of low- and medium-dose clonidine on human NREM-REM sleep proportion. Psychiatry Clin Neurosci 58: 138–144CrossRefPubMedGoogle Scholar
  50. 50.
    Miyazaki T, Kuwano H, Kato H et al. (2003) Correlation between serum melatonin circadian rhythm and intensive care unit psychosis after thoracic esophagectomy. Surgery 133: 662–668CrossRefPubMedGoogle Scholar
  51. 51.
    Mundigler G, Delle-Karth G, Koreny M et al. (2002) Impaired circadian rhythm of melatonin secretion in sedated critically ill patients with severe sepsis. Crit Care Med 30: 536–540CrossRefPubMedGoogle Scholar
  52. 52.
    Nieuwenhuijs D, Coleman EL, Douglas NJ et al. (2002) Bispectral index values and spectral edge frequency at different stages of physiologic sleep. Anesth Analg 94: 125–129, tableCrossRefPubMedGoogle Scholar
  53. 53.
    Novaes MA, Aronovich A, Ferraz MB, Knobel E (1997) Stressors in ICU: patients‘ evaluation. Intensive Care Med 23: 1282–1285CrossRefPubMedGoogle Scholar
  54. 54.
    Olofsson K, Alling C, Lundberg D, Malmros C (2004) Abolished circadian rhythm of melatonin secretion in sedated and artificially ventilated intensive care patients. Acta Anaesthesiol Scand 48: 679–684CrossRefPubMedGoogle Scholar
  55. 55.
    Onen SH, Alloui A, Gross A et al. (2001) The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects. J Sleep Res 10: 35–42CrossRefPubMedGoogle Scholar
  56. 56.
    Orr WC, Stahl ML (1977) Sleep disturbances after open heart surgery. Am J Cardiol 39: 196–201CrossRefPubMedGoogle Scholar
  57. 57.
    Ozone M, Itoh H, Yamadera W et al. (2000) Changes in subjective sleepiness, subjective fatigue and nocturnal sleep after anaesthesia with propofol. Psychiatry Clin Neurosci 54: 317–318CrossRefPubMedGoogle Scholar
  58. 58.
    Papadimitriou GN, Linkowski P (2005) Sleep disturbance in anxiety disorders. Int Rev Psychiatry 17: 229–236CrossRefPubMedGoogle Scholar
  59. 59.
    Parthasarathy S, Tobin MJ (2002) Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 166: 1423–1429CrossRefPubMedGoogle Scholar
  60. 60.
    Pollmacher T, Haack M, Schuld A et al. (2002) Low levels of circulating inflammatory cytokines – do they affect human brain functions? Brain Behav Immun 16: 525–532CrossRefPubMedGoogle Scholar
  61. 61.
    Rauchs G, Desgranges B, Foret J, Eustache F (2005) The relationships between memory systems and sleep stages. J Sleep Res 14: 123–140CrossRefPubMedGoogle Scholar
  62. 62.
    Rechtschaffen A, Kales A (eds) (1968) A manual for standardized terminology, techniques and scoring system for sleep stages of human subjects. Public Health Service, WashingtonGoogle Scholar
  63. 63.
    Rechtschaffen A, Bergmann BM, Everson CA et al. (2002) Sleep deprivation in the rat: X. Integration and discussion of the findings. 1989. Sleep 25: 68–87PubMedGoogle Scholar
  64. 64.
    Richards KC (1998) Effect of a back massage and relaxation intervention on sleep in critically ill patients. Am J Crit Care 7: 288–299PubMedGoogle Scholar
  65. 65.
    Richards KC, O’Sullivan PS, Phillips RL (2000) Measurement of sleep in critically ill patients. J Nurs Meas 8: 131–144PubMedGoogle Scholar
  66. 66.
    Rincon HG, Granados M, Unutzer J et al. (2001) Prevalence, detection and treatment of anxiety, depression, and delirium in the adult critical care unit. Psychosomatics 42: 391–396CrossRefPubMedGoogle Scholar
  67. 67.
    Rotondi AJ, Chelluri L, Sirio C et al. (2002) Patients‘ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med 30: 746–752CrossRefPubMedGoogle Scholar
  68. 68.
    Rundshagen I, Schnabel K, Wegner C, am Esch S (2002) Incidence of recall, nightmares, and hallucinations during analgosedation in intensive care. Intensive Care Med 28: 38–43CrossRefPubMedGoogle Scholar
  69. 69.
    Schaefer KM, Swavely D, Rothenberger C et al. (1996) Sleep disturbances post coronary artery bypass surgery. Prog Cardiovasc Nurs 11: 5–14Google Scholar
  70. 70.
    Schenck CH, Mahowald MW (1991) Injurious sleep behavior disorders (parasomnias) affecting patients on intensive care units. Intensive Care Med 17: 219–224CrossRefPubMedGoogle Scholar
  71. 71.
    Schittecatte M, Garcia-Valentin J, Charles G et al. (1995) Efficacy of the „clonidine REM suppression test (CREST)“ to separate patients with major depression from controls; a comparison with three currently proposed biological markers of depression. J Affect Disord 33: 151–157CrossRefPubMedGoogle Scholar
  72. 72.
    Shelly MP, Sultan MA, Bodenham A, Park GR (1991) Midazolam infusions in critically ill patients. Eur J Anaesthesiol 8: 21–27PubMedGoogle Scholar
  73. 73.
    Shilo L, Dagan Y, Smorjik Y et al. (1999) Patients in the intensive care unit suffer from severe lack of sleep associated with loss of normal melatonin secretion pattern. Am J Med Sci 317: 278–281CrossRefPubMedGoogle Scholar
  74. 74.
    Shilo L, Dagan Y, Smorjik Y et al. (2000) Effect of melatonin on sleep quality of COPD intensive care patients: a pilot study. Chronobiol Int 17: 71–76CrossRefPubMedGoogle Scholar
  75. 75.
    Simpson T, Lee ER, Cameron C (1996) Patients‘ perceptions of environmental factors that disturb sleep after cardiac surgery. Am J Crit Care 5: 173–181PubMedGoogle Scholar
  76. 76.
    Sin DD, Fitzgerald F, Parker JD et al. (1999) Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure. Am J Respir Crit Care Med 160: 1101–1106PubMedGoogle Scholar
  77. 77.
    Smith C (2001) Sleep states and memory processes in humans: procedural versus declarative memory systems. Sleep Med Rev 5: 491–506CrossRefPubMedGoogle Scholar
  78. 78.
    Soldatos CR, Dikeos DG, Whitehead A (1999) Tolerance and rebound insomnia with rapidly eliminated hypnotics: a meta-analysis of sleep laboratory studies. Int Clin Psychopharmacol 14: 287–303PubMedGoogle Scholar
  79. 79.
    Spengler CM, Shea SA (2000) Sleep deprivation per se does not decrease the hypercapnic ventilatory response in humans. Am J Respir Crit Care Med 161: 1124–1128PubMedGoogle Scholar
  80. 80.
    Spiegel K, Sheridan JF, Cauter E van (2002) Effect of sleep deprivation on response to immunization. JAMA 288: 1471–1472CrossRefGoogle Scholar
  81. 81.
    Stickgold R, Walker MP (2005) Memory consolidation and reconsolidation: what is the role of sleep? Trends Neurosci 28: 408–415CrossRefPubMedGoogle Scholar
  82. 82.
    Thase ME (2005) Correlates and consequences of chronic insomnia. Gen Hosp Psychiatry 27: 100–112CrossRefPubMedGoogle Scholar
  83. 83.
    Trachsel L, Schreiber W, Holsboer F, Pollmacher T (1994) Endotoxin enhances EEG alpha and beta power in human sleep. Sleep 17: 132–139PubMedGoogle Scholar
  84. 84.
    Treggiari-Venzi M, Borgeat A, Fuchs-Buder T et al. (1996) Overnight sedation with midazolam or propofol in the ICU: effects on sleep quality, anxiety and depression. Intensive Care Med 22: 1186–1190PubMedGoogle Scholar
  85. 85.
    Walder B, Francioli D, Meyer JJ et al. (2000) Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels. Crit Care Med 28: 2242–2247CrossRefPubMedGoogle Scholar
  86. 86.
    Walder B, Tramer MR, Blois R (2001) The effects of two single doses of tramadol on sleep: a randomized, cross-over trial in healthy volunteers. Eur J Anaesthesiol 18: 36–42CrossRefPubMedGoogle Scholar
  87. 87.
    Walker MP, Stickgold R (2006) Sleep, memory, and plasticity. Annu Rev Psychol 57: 139–166CrossRefPubMedGoogle Scholar
  88. 88.
    Weitzenblum E, Chaouat A (2004) Sleep and chronic obstructive pulmonary disease. Sleep Med Rev 8: 281–294CrossRefPubMedGoogle Scholar
  89. 89.
    White DP, Douglas NJ, Pickett CK et al. (1983) Sleep deprivation and the control of ventilation. Am Rev Respir Dis 128: 984–986PubMedGoogle Scholar
  90. 90.
    Zeitlhofer J, Schmeiser-Rieder A, Tribl G et al. (2000) Sleep and quality of life in the Austrian population. Acta Neurol Scand 102: 249–257CrossRefPubMedGoogle Scholar
  91. 91.
    Zimmerman L, Nieveen J, Barnason S, Schmaderer M (1996) The effects of music interventions on postoperative pain and sleep in coronary artery bypass graft (CABG) patients. Sch Inq Nurs Pract 10: 153–170PubMedGoogle Scholar

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© Springer Medizin Verlag 2006

Authors and Affiliations

  1. 1.Service d’AnesthésiologieHôpitaux UniversitairesGenève 14Schweiz
  2. 2.Klinik für Anästhesiologie und operative IntensivmedizinCampus Mitte und Campus Virchow-Klinikum, Universitätsmedizin Berlin – CharitéDeutschland

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